Should the Diastatic Syndesmosis be Stabilized in Advanced Pronation-External Rotation Ankle Injuries? A Retrospective Cohort Comparison

Background: Ankle injuries with the advanced pronation-external rotation (PE) type are relatively uncommon and the debate about whether the diastatic syndesmosis should be stabilized concomitantly has yet achieved a consensus. Comparison of using (Group 1) or non-using (Group 2) screw stabilization for the diastatic syndesmosis was performed retrospectively. Methods: With the 10-year period, 81 consecutive adult patients with advanced PE ankle injuries (stage 3 or 4 PE type) were treated. After malleolar fractures were internally stabilized with screws and plates, the syndesmotic stability was re-checked by external rotation and hook tests. The necessity of insertion of cortical screws to stabilize diastatic syndesmosis was decided by the individual orthopedic surgeon. The outcomes of both approaches were compared. Results: Seventy-one patients were followed for at least one year (87.7%; average, 2 years; range, 1-11 years). Group 1 had 22 patients and Group 2, 49 patients. The union rate in Group 1 was 100% (22 / 22) and in Group 2, 91.8% (45 / 49; p= 0.30). Syndesmosis re-diastasis occurred in 13.6% (3 / 22) of Group 1 and 30.6% (15 / 49) of Group 2 (p= 0.13). Satisfactory ankle function was noted in 86.4% (19 / 22) of Group 1 and 65.3% (32 / 49) of Group 2 (p= 0.07). Conclusion: Although clinical comparison cannot demonstrate statistical difference, screw stabilization of the diastatic syndesmosis may guarantee safer results. The statistical insignificance may be due to insufficient sample sizes. Clinically and theoretically, insertion of syndesmotic screws to promote ligament healing may be reasonable.

An Exceptional Avulsion Fracture Above the Medial Malleolus: A Retrospective Case Series

The Lauge-Hansen classification does not cover all types of ankle injuries. The present report details three cases of exceptional fragment of the medial tibia that differed from the traditional Lauge-Hansen supination–external rotation and pronation–external rotation fracture patterns. The information obtained from this study will be helpful for conducting basic research of this condition and determining appropriate surgical approaches.

Ankle fracture – correlation of Lauge-Hansen classification and patient reported fracture mechanism

Category: Trauma Introduction/Purpose: The genetic Lauge-Hansen classification is considered to provide a link between mechanism of ankle injury and resulting fracture morphology. In this study, we addressed the question of agreement between the mechanism of the fracture as postulated by the Lauge-Hansen classification and mechanism reported by the patient in rotational ankle fractures. Understanding of the actual mechanisms of ankle fracture may guide treatment decisions. Methods: Of 110 screened patients with acute malleolar fractures, 78 were able to provide information on their fracture mechanism and were included in the study. The study group consisted of 43 women and 35 men with a mean age of 47.8 (range 19.5-88.4) years. Patients were asked to describe the direction of deformation with primary question being pronation and supination as demonstrated by the examiner. As hyperplantarflexion and hyperdorsiflexion has been spontaneously reported by the patients, these directions were added to the analysis. Radiographs were analyzed according to Lauge-Hansen classification and compared with fracture mechanisms reported by the patients. Results: The majority (35/78 = 44.8%) of patients reported pronation as their fracture mechanism, 27 (34.6%) patients reported supination, 15 (19.2%) patients reported hyperplantarflexion (3 pure, one combined with pronation and 11 combined with supination), and 1 patient reported hyperdorsiflexion combined with pronation. Radiographs revealed 61 supination-external rotation (79%), 1 supination-adduction (1.3%), 14 pronation-external rotation (18%), 1 pronation-abduction (1.3%) fractures. One x-ray was unclassifiable with the Lauge-Hansen classification. The patient reported mechanisms were in concordance with the mechanism deducted from the x-rays in 49% of cases. Only 17% of patients who recalled a pronation trauma actually had radiographs classified as pronation fractures while 76% of patients who recalled a supination trauma were also radiographically classified as having sustained supination type fractures. Conclusion: The Lauge-Hansen classification should be used with caution for determining the actual mechanism of injury as it was able to predict the patient reported fracture mechanism in less than 50% of cases. A substantial percentage of fractures appearing radiographically as supination type injuries may have been actually produced by a pronation fracture mechanism.

Effect of Ankle Position on Tibiotalar Motion With Screw Fixation of the Distal Tibiofibular Syndesmosis in a Fracture Model

Background: Anatomic reduction and fixation of the syndesmosis in traumatic injuries is paramount in restoring function of the tibiotalar joint. While overcompression is a potential error, recent work has called into question whether ankle position during fixation really matters in this regard. Our study aimed to corroborate more recent findings using a fracture model that, to our knowledge, has not been previously tested. Methods: Twenty cadaver leg specimens were obtained and prepared. Each was tested for tibiotalar motion under various conditions: intact syndesmosis, intact syndesmosis with lag screw compression, pronation external rotation type 4 (PER-4) ankle fracture with syndesmotic disruption, and single-screw syndesmotic fixation followed by plate and screw fracture and syndesmotic screw fixation. In each situation, the ankle was held in alternating plantarflexion and dorsiflexion when inserting the syndesmotic screw with the subsequent amount of maximal dorsiflexion being recorded following hand-tight lag screw fixation. Results: While ankle range of motion increased significantly with creation of the PER-4 injury, under no condition was there a statistically significant change in maximal dorsiflexion angle. Conclusion: Ankle position during distal tibiofibular syndesmosis fixation did not limit dorsiflexion of the ankle joint. Clinical Relevance: Our findings suggest that maximal dorsiflexion during syndesmotic screw fixation may not be necessary.

Ultrasound Guidance in Performing a Tendoscopic Surgery to Treat Posterior Tibial Tendinitis: A Useful Tool?

A 25-year-old man with a pronation-external rotation type of fracture was surgically treated using a fibular plate. Five years later, he underwent resection of bone hyperplasia because of the ankle pain and limitation of range of motion. Thereafter, the left ankle became intermittently painful, which persisted for about one year. He presented at the age of 43 with persistent ankle pain. Physical and image analysis findings indicated a diagnosis of posttraumatic posterior tibial tendinitis, which we surgically treated using tendoscopy. Endoscopic findings showed tenosynovitis and fibrillation on the tendon surface. We cleaned and removed the synovium surrounding the tendon and deepened the posterior tibial tendon groove to allow sufficient space for the posterior tibial tendon. Full weight-bearing ambulation was permitted one day after surgery and he returned to his occupation in the construction industry six weeks after surgery. The medial aspect of the ankle was free of pain and symptoms at a review two years after surgery. Although tendoscopic surgery for stage 1 posterior tibial tendon dysfunction has been reported, tendoscopic surgery to treat posttraumatic posterior tibial tendinitis has not. Our experience with this patient showed that tendoscopic surgery is useful not only for stage 1 posterior tibial dysfunction, but also for posttraumatic posterior tibial tendinitis.